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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202340
Report Date: 01/26/2024
Date Signed: 01/29/2024 09:16:10 AM


Document Has Been Signed on 01/29/2024 09:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:VENETIAN RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202340
ADMINISTRATOR:PAZ BILKEYFACILITY TYPE:
740
ADDRESS:4649 VENICE WAYTELEPHONE:
(408) 873-1670
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:6CENSUS: 5DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Virginia Quezada, House MangerTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manager (HM) Virginia Quezada .

LPA reviewed 3 resident files and 3 staff files.

LPA toured the facility with HM. LPA observed 5 residents (R1 - R5) and 2 staff (S1 - S2)in the facility.

License, personal right posters and Administrator Certificate were observed in the facility.

LPA inspected living room, family room, dinning room, kitchen. There are 2 restrooms for residents, a restroom for staff, 2 resident shared rooms, 2 resident single rooms, and 1 staff live-in room in facility. Two days perishable foods and seven nonperishable foods were observed sufficient.

Room temperature was observed at 74 degree F, hot water temperature was observed at 110 degree F. The temperature of the refrigerator is 40 degree F, and the temperature of the freezer is 0 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. Fire extinguisher was serviced on 5/17/2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

First Aid box, flash light and night lights were observed in the facility.

Deficiency noted today. See LIC809-D. This report was provided to HM for signature. A copy of this report was emailed to HM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/29/2024 09:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: VENETIAN RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, and record review, the licensee did not comply with the section cited above in that staff files were observed incomplete and not up to date, which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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House manager stated the facility will submit a plan of correction by the POC due date to make staff files complete and up to date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/29/2024 09:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: VENETIAN RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, and record review, the licensee did not comply with the section cited above in that resident files were onserved incomplete and not up to date, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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House Manager stated the facility will submit a plan of correction by the POC due date to make the resident files complete and up to date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3